1. Dose. The more a pregnant woman drinks, the greater the risk of FAS. However, as reflected in the U.S. Surgeon General’s advisory, there is no known safe amount of alcohol during pregnancy Prenatal alcohol exposure to one or more drinks per day is associated with reduced birth weight and intrauterine growth retardation, spontaneous abortion, preterm delivery, and stillbirth.

2. Pattern. Drinking patterns that create high peak blood alcohol level pose the greatest risk. Binge drinking is felt to be particularly risky. A binge is defined as the consumption of four alcoholic drinks per drinking occasion. One drink is defined as 12 oz of beer or wine cooler, 5 oz of wine, or 1.5 oz of liquor.

3. Timing. First trimester exposure poses risks to major structures; second trimester exposure poses risk of spontaneous abortion; and third trimester exposure has the greatest impact on height, weight, and brain growth. However, no period of pregnancy appears to be safe for drinking since damage can occur at any point after conception. The brain can be affected by alcohol in all the three trimesters.

4. Genetic sensitivity or effects of metabolism. There may be genetic differences in a woman’s ability to metabolize alcohol and in how a fetus is affected. The fetus is limited in its ability to metabolize alcohol and alcohol levels in the fetus are thought to be higher and present for a more prolonged period when compared with maternal levels.

5. Maternal nutrition. Alcohol intake can have direct or indirect effects on the nutritional status of the fetus either because alcohol abusers often have a poor diet or because alcohol can interfere with the absorption or processing of nutrients such as thiamine, magnesium, zinc, and folate.

6. Maternal age. Children of mothers who are older than 30 years have a higher risk of negative outcomes following prenatal alcohol exposure.

7. Parity. Studies suggest that the risk of having a child with FAS increases with each successive pregnancy. The rate increases from 0.2-1.5/1000 to 771/1000 live births for the younger sibling of a child with FAS.

1. Documentation of three facial abnormalities; smooth philtrum, thin vermillion border, and small palpebral fissures. These features should be assessed using a standardized method such as the University of Washington Lip-Philtrum Guide (www.fasdpn.org) and a palpebral fissure normogram standardized for age and racial norms.

2. Documentation of growth deficits (weight and/or length, at or below the 10th percentile). The CDC guidelines state that the weight or height growth deficit can occur at anytime beginning in the prenatal period (adjusted for age, sex, gestational age, and race/ethnicity).

3. Documentation of CNS abnormality (structural, neurological, or functional) CNS abnormalities may be structural, neurological, or functional. Structural abnormalities have been described in a number of ways and include the following: (1) The CDC 2004 Guidelines includes a head size at or below 10th percentile adjusted for age and sex, (2) the University of Washington Diagnostic Guide includes microcephaly or an occipital-frontal circumference less than two standard deviations, and/or (3) abnormalities on neuroimaging that are believed to have occurred prenatally (e.g., reduction in size of corpus callosum, cerebellum, or basal ganglia). Neurological findings include seizures not attributable to postnatal insults or fever, poor coordination, or visual motor difficulties. CNS dysfunction includes deficits in cognition, executive function, motor function, attentional control, social skills, adaptive skills, memory, and language, among others. There can be a wide range of severity of these challenges. About 25% of children with FAS have IQs below 70. Those who have higher IQs may have persistent neurobehavioral problems that result in learning difficulties (e.g., mathematics disorder), poor comprehension, slow processing speed, sleep disorders, cognitive rigidity, and impaired problem-solving abilities. The relatively higher IQs of these individuals, coupled with absence of gross facial dysmorphology, makes them more prone to be labeled as aggressive, oppositional, willful, or lazy rather than neurobehaviorally challenged.

4. Documentation of alcohol exposure. Although it is important to document alcohol exposure, this is often difficult to obtain. Birth mothers may be hesitant to provide the information, and when the child is adopted, exposure to prenatal alcohol may be unknown. When the FAS diagnostic criteria is met on the basis of the characteristic facial growth and CNS abnormalities, confirmation of maternal alcohol exposure is helpful but not essential for the diagnosis. There are clinical criteria to identify the other FASDs, but for the individuals who do not meet full facial growth and CNS criteria for FAS, there should always be confirmed prenatal alcohol exposure.

1. Pregnancy history. “During this pregnancy, how many times a week did you drink beer, wine, or liquor? How many cans, glasses, or drinks each time?” (Or in the case of a foster or adopted child, “Do you know how much alcohol was consumed during this pregnancy?”). Remember to ask about alcohol consumption prior to knowledge of the pregnancy, as some women may not have had knowledge until several weeks to months into the pregnancy (e.g., certain women with irregular periods, or who become pregnant while on a contraceptive). Binge drinking (consuming four or more standard drinks on a single occasion) is considered particularly harmful, and so is chronic drinking throughout the pregnancy.